Endoscopic Repairs of Sinonasal Cerebrospinal Leaks: Outcome and Prognostic Factors

Dural sinus narrowing in patients with spontaneous anterior skull base cerebrospinal fluid leak

Objectives

Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak.

Methods

A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test.

Results

Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59-0.93, p < .001).

Conclusion

The prevalence of DVS narrowing in patients with sCSF leaks is substantial and likely greater than the general population. Moreover, there appears to be narrowing in most patients with sCSF leak. Preoperative radiological evaluation of the DVS using MR venography may be useful in patients with sCSF leaks as DVS stenosis may be an underdiagnosed etiology. Further study is needed to evaluate this.

Level of Evidence

IV.

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea-Experience from Three Southeast Asian Countries

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea requires proper management to avoid disastrous consequences. The objectives of this study were to ascertain the patient characteristics, etiologies, sites of defect, skull base configurations, methods of investigation, and management outcomes of CSF rhinorrhea.

METHODS

A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes.

RESULTS

A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days.

CONCLUSIONS

Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.

Outcome of the endoscopic repair of frontal sinus cerebrospinal fluid leak

Introduction

and Objectives: Leakage of cerebrospinal fluid (CSF) from the frontal sinus is a challenging condition facing the ENT surgeon. Repair of this condition has been changed nowadays due to the newer instruments and techniques of nasal endoscopy. This study aims to evaluate the outcome of frontal sinus CSF leak endoscopic repair.

Patients and methods

Twenty-seven patients who had frontal sinus CSF leaks were included in this study. They were 9 females and 18 males. They underwent endoscopic repair of the leak site at the period of five years from 2015 to 2020. A retrospective evaluation of these patients includes reconstructive procedures, complications, and postoperative follow-up.

Results

The frontal leaks were present in the frontal recess (8 patients, 29.6%), ethmoidal roof (5 patients, 18.5%), and the majority was in the posterior wall (14 patients, 51.9%); 11 in the medial side and 3 in the lateral side. All cases, 27 (100%) were treated successfully, no failed treatment was observed. Postoperative complications were minimal; two patients had elevated intracranial pressure (ICP), infection with fever were found in four patients (7.4%), and meningitis was observed in only two cases (7.4%), treated conservatively.

Conclusion

For frontal sinus CSF leak repair, the endonasal endoscopic approach is the treatment of choice due to higher success rates and lower morbidity profile. A favorable result is possible with proper diagnosis, precise localization, and an appropriate strategy.

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CSF leakage from the frontal sinus is a challenging condition for ENT surgeons.

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Repair has been changed nowadays due to the newer techniques of nasal endoscopy.

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We report favorable results of the endonasal endoscopic approach in 27 patients.

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Proper diagnosis and precise localization are acheived.

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature

BACKGROUND

Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures.

METHODS

PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes.

RESULTS

We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery.

CONCLUSIONS

ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks

ABSTRACT

Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Multifocal Skull Base Defects With Associated Spontaneous Cerebrospinal Fluid Leaks

OBJECTIVE

Spontaneous cerebrospinal fluid (CSF) leaks are thought to arise due to elevated intracranial pressure which is distributed across the skull base, potentially predisposing the development of multifocal CSF leaks. The aims of this study are to evaluate the characteristics of this population at presentation and surgical outcomes.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Patients 18 years or older with spontaneous CSF leak diagnosis were eligible for study inclusion. Multifocal spontaneous CSF leak was defined as leaks originating from more than one skull base defect at anatomically distinct subsites.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Clinical presentation and surgical outcome.

RESULTS

Two hundred ninety-three patients with diagnosis of spontaneous CSF leak were identified. Of these, 11 (3.8%) were characterized as having multifocal spontaneous CSF leaks. Mean body mass index was significantly higher in multifocal CSF leak patients (31.5 ± 8.5 vs 46.2 ± 9.9, p < 0.0001). There was also higher prevalence of women (100% vs 63.8%, p = 0.012) and African-Americans (63.6% vs 23.4%, p = 0.003). The overall success rate of CSF leak repair was 95%. Fifty percent of patients developed headaches or blurry vision after surgical repair, and two patients required ventriculoperitoneal shunting.

CONCLUSIONS

Multifocal spontaneous CSF leaks are rare and occurred in 3.8% of patients with spontaneous CSF. These patients were morbidly obese and more likely to be female and African American. Surgical repair conferred excellent outcomes. However, these patients have high risk of developing symptoms suggestive of elevated intracranial pressure postoperatively and should be counseled accordingly.

Endoscopic management of frontal sinus CSF leaks

Introduction

Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition.

Objective

To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach.

Methods

A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined.

Results

Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 − 41 months).

Conclusion

Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Cerebrospinal Fluid Leak Following Nasal Packing for Epistaxis

Anterior epistaxis is commonly treated with Merocel nasal packing insertion. A 63-year-old male patient showed a cerebrospinal fluid rhinorrhea and pneumocephalus immediately after insertion of a Merocel tampon used for spontaneous right anterior epistaxis. He later developed fever and headache. This clinical report is to highlight how the nasal merocel should be positioned by specialized personnel and to describe how to manage this type of complication.

Spontaneous Nasal Cerebrospinal Fluid Leak Repaired With Single-Layer Mucoperichondrial Graft: Long-term Results

Background

Spontaneous cerebrospinal fluid leak (sCSFL) has been historically related to obesity and elevated intracranial pressure (ICP), with a lower rate of success of endoscopic repair reported in the literature. Moreover, defects related to this condition have been largely repaired with multilayer reconstructions and pedicled flaps. Long-term postoperative results have not been appropriately discussed yet.

Objective

The aim of this study is to investigate the outcome of a cohort of patients treated with single-layer mucoperichondrial graft.

Methods

A retrospective review of clinical records of a consecutive series of patients who underwent endonasal endoscopic surgery for sCSFL was carried out at a tertiary care referral center for skull base pathologies. All patients underwent reconstruction with single-layer mucoperichondrial free graft. Local flap failures and postoperative outcomes, in terms of recurrence of sCSFL or brain herniation, were registered.

Results

Neither intraoperative nor perioperative complications were reported. Definitive closure was achieved in 27 of 29 (93%) patients after the first attempt, while in 2 cases, a revision surgery was required. In both of these, an inadequate position of the graft was detected and was repaired likewise with the same mucoperichondrial graft. None of the patients required postoperative lumbar drain placement. After a median follow-up period of 57 months, only 1 patient developed a meningocele without CSFL about 2 years after surgery at the contralateral lateral recess of the sphenoid sinus. None of the patients reported symptoms referable to elevated ICP nor underwent ventricular derivation.

Conclusions

Single-layered mucoperichondrial free graft was safe and effective in the majority of the examined patients. In 7% of the study population, a surgical revision was necessary due to local failure of the graft. However, during long-term follow-up, only 1 case of recurrent meningocele without CSFL was reported in a patient who presented borderline ICP.

Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Leaks Using Multilayer Composite Graft and Vascularized Pedicled Nasoseptal Flap Technique

Background

Endoscopic repair of cerebrospinal fluid (CSF) fistulas is a fundamental practice in anterior skull base surgery due to high success rates and low morbidity profile. However, spontaneous CSF (sCSF) leaks have the highest recurrence rate compared to other etiologies. The most effective management is undetermined due to variations in graft materials and limited evidence.

Objective

We present the largest study of a standardized endoscopic repair technique for sCSF leaks.

Methods

Single-institution retrospective review of patients who underwent endoscopic sCSF leak repair between October 2011 and January 2018. All patients underwent repair using a temporary lumbar drain, intrathecal fluorescein, and multilayer reconstruction using bilayered fascia lata autograft and vascularized nasoseptal flap.

Results

Twenty patients (100% female, mean age: 53.2 years) with 25 separate sCSF leak sites were included. Obesity was present in 15 of 20 patients (mean body mass index [BMI] = 35.3). No patients had previous sinus surgery. Locations of skull base defects included: cribriform plate (44%), ethmoid (32%), lateral sphenoid (12%), and planum sphenoidale (12%). The mean follow-up was 22.8 months and 92% of the leak sites (23/25) were successfully repaired primarily. There were no neurological complications or cases of meningitis. Two patients (mean BMI = 52) with persistent postoperative CSF leaks and elevated intracranial pressure were successfully managed with ventriculoperitoneal shunt placement. BMI was associated with likelihood of repair failure (P = .003).

Conclusions

At our institution, endoscopic repair of sCSF leaks using a composite autograft of fascia and a nasoseptal flap demonstrates high success rates. Elevated BMI was a statistically significant risk factor for revision.

Reconstruction of the skull base in spontaneous rhinoliquorrhea

Objective/Hypothesis: Spontaneous rhinoliquorrhea often occurs due to defects of the skull base. It is often misinterpreted as rhinitis and is surgically the most difficult rhinoliquorrhea entity to close. Methods: We conducted a retrospective chart analysis of patients that were diagnosed with spontaneous rhinoliquorrhea at the University Hospital Bonn between 2001 and 2017. Results: Overall, twelve patients were included in this study. On average, the time between occurrence of nasal discharge and diagnoses of rhinoliquorrhea was 123 days. In ten patients, the localization of the skull base defect could be localized by computed tomography or MRI cisternography. Ten patients underwent surgery, of which 9 remained recurrence free. One patient underwent revision surgery and from thereon was recurrence free. Conclusion: Spontaneous rhinoliquorrhea still remains a diagnostic and therapeutic challenge. Whenever persistent watery nasal discharge appears in a patient, rhinoliquorrhea must be considered. Endoscopic surgical reconstruction of the skull base is the therapeutic gold standard and should be attempted as soon as the diagnosis is secured.

Endoscopy-Assisted Frontal Sinus Obliteration

Comminuted fractures of the anterior table of the frontal sinus involving frontonasal ducts are traditionally treated with sinus obliteration. This technique entails precise mucosa removal which requires unimpeded visualization of the bony recesses. To achieve adequate access to the mucosa, temporary removal of a large part of the frontal bone may often be necessary. This in turn increases fracture comminution requiring placement of additional hardware associated with the risk for bony malalignment, infection, plate palpability, and visibility, especially in thin-skin individuals. Endoscopy, offering magnified visualization and less invasive access, is reported to be beneficial in sinus injury management. Therefore, it may be also considered an adjunct in open-approach management of severely comminuted fractures.The authors' patient suffered from comminuted fractures of the anterior and posterior tables of the frontal sinus and nasal bone fractures with involvement of the frontonasal ducts. Due to the extent of the injury he underwent frontal sinus obliteration procedure using the pericranial flap. To avoid additional osteotomy, endoscopic approach was undertaken to achieve the complete removal of the sinus mucosa. The fracture by itself offered an "access port" for the endoscope and electrical cautery. The patient's recovery was uneventful.Endoscopy employed in frontal sinus obliteration appears to be instrumental in obtaining meticulous mucosa removal, obviating the need for additional osteotomy of the frontal bone.

Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years

PURPOSE

Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging.

METHODS

In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded.

RESULTS

Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof-especially in the cribriform plate-and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary.

CONCLUSIONS

Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary.